Project Summary/Abstract: Many studies have shown that racial and ethnic minorities do not receive therapeutic medical procedures at the same rates as non-Hispanic whites, with the strongest evidence of these racial disparities in the utilization of invasive cardiac procedures. The causes of these racial disparities remain unclear, but geographic and financial access, underlying morbidity, insurance status, and income cannot fully explain the differences. There is suggestive evidence that a contributing factor is a difference in the rate at which physicians offer these procedures to patients based on race and/or gender, and that such biases may be present in medical students. This innovative, multidisciplinary, multimethod study will investigate the prevalence and determinants of racial and gender biases in medical decision-making under conditions of scientific uncertainty of senior medical students. It will further develop information about the dynamics by which non-clinical factors become part of student medical decision-making, and the training environment in which this takes place. In doing so, the study will provide essential guidance to medical educators and developers of cultural competency training who aim to reduce the impact of this social determinant of health and accompanying racial and gender disparities in health service delivery. A nationwide mail survey of senior allopathic medical students will first be conducted to determine the prevalence of such biases using a set of clinical vignettes in which the race and gender of the patient will vary among the sample. The influence of patient race, gender and socioeconomic status on the rates of procedural recommendation by the students will be analyzed. Ecological case studies will then be conducted at each of 14 purposively selected medical schools to explore the context and dynamics of formation of student medical decision-making. Schools for the case studies will be selected based on summaries of response patterns to the survey, with sampling of schools for study that demonstrate greater or lesser degrees of influence of race and gender on their students' responses. In-depth interviews of students, faculty and staff key informant interviews, examination of cultural competency and student curricula and of admission processes are some of the data collection processes that will be used to explore the context in which student decision-making processes are formed, reinforced, or reduced. The findings of the combined survey and case studies will be used to prepare reports for schools, policy makers, and peer-reviewed scientific presentations and publications. The specific objective of this study is to develop and disseminate evidence-based recommendations for medical educators and developers of cultural competency training interested in reducing the role that such biases play in racial and gender disparities in health services delivery.